Multi-country collaborative citizen science projects to co-design cardiovascular disease prevention strategies and advocacy: findings from Ethiopia, Malawi, Rwanda, and South Africa.

BACKGROUND: Cardiovascular diseases (CVD) were responsible for 20.5 million annual deaths globally in 2021, with a disproportionally high burden in sub-Saharan Africa (SSA). There is growing evidence of the use of citizen science and co-design approaches in developing interventions in different fields, but less so in the context of CVD prevention interventions in SSA. This paper reports on the collaborative multi-country project that employed citizen science and a co-design approach to (i) explore CVD risk perceptions, (ii) develop tailored prevention strategies, and (iii) support advocacy in different low-income settings in SSA. METHODS: This is a participatory citizen science study with a co-design component. Data was collected from 205 participants aged 18 to 75 years in rural and urban communities in Malawi, Ethiopia and Rwanda, and urban South Africa. Fifty-one trained citizen scientists used a mobile app-based (EpiCollect) semi-structured survey questionnaire to collect data on CVD risk perceptions from participants purposively selected from two communities per country. Data collected per community included 100-150 photographs and 150-240 voice recordings on CVD risk perceptions, communication and health-seeking intentions. Thematic and comparative analysis were undertaken with the citizen scientists and the results were used to support citizen scientists-led stakeholder advocacy workshops. Findings are presented using bubble graphs based on weighted proportions of key risk factors indicated. RESULTS: Nearly three in every five of the participants interviewed reported having a relative with CVD. The main perceived causes of CVD in all communities were substance use, food-related factors, and litter, followed by physical inactivity, emotional factors, poverty, crime, and violence. The perceived positive factors for cardiovascular health were nutrition, physical activity, green space, and clean/peaceful communities. Multi-level stakeholders (45-84 persons/country) including key decision makers participated in advocacy workshops and supported the identification and prioritization of community-specific CVD prevention strategies and implementation actions. Citizen science-informed CVD risk screening and referral to care interventions were piloted in six communities in three countries with about 4795 adults screened and those at risk referred for care. Health sector stakeholders indicated their support for utilising a citizen-engaged approach in national NCDs prevention programmes. The citizen scientists were excited by the opportunity to lead research and advocacy. CONCLUSION: The collaborative engagement, participatory learning, and co-designing activities enhanced active engagement between citizen scientists, researchers, and stakeholders. This, in turn, provided context-specific insights on CVD prevention in the different SSA settings.

The effects of COVID-19 mitigation measures on physical activity (PA) participation among adults in Rwanda: An online cross-sectional survey.

INTRODUCTION: More than a third of the world's population was under full or partial lockdown during COVID-19 by April 2020. Such mitigation measures might have affected participation in various Physical activity (PA) and increased sedentary time. This study aimed to assess the effect of the COVID-19 mitigation measures on participation of adults in various PA types in Rwanda. METHODS: We collected data from conveniently selected participants at their respective PA sites. We assessed the variation in time spent doing in four types of PA (Work related PA, PA in and around home, transportation PA and recreation, sport, and leisure purpose) across different pandemic period. We also evaluated the sedentary time over the weekdays and on the weekends. RESULTS: A total of 1136 participants completed online assisted questionnaire. 71.4% were male, 83% of the study participants aged 18 to 35 years (mean = 29, (standard deviation = 7.79). Mean time spent doing vigorous PA as part of the work dropped from 84.5 minutes per day before COVID-19 to 58.6 minutes per day during lockdown and went back to 81.5 minutes per day after the lockdown. Time spent sitting on weekdays increased from 163 before COVID-19 to 244.5 minutes during lockdown and to 166.8 minutes after lockdown. Sitting time on weekend increased from 150 before COVID-19 to 235 minutes during lockdown and to 151 minutes after lockdown. Sleeping time on weekdays increased from 7.5 hours per day before COVID-19 to 9.9 hours during lockdown and to 7.5 hours after lockdown while it increased from 8 hours before COVID-19 to 10 hours during lockdown and to 8 hours per day after lockdown during weekends. CONCLUSION: The study emphasizes the significance of diverse PA, including home-based programs, during pandemics like COVID-19. It suggests promoting PA types like work-related, transportation, and domestic works during lockdown and similar period.

Models of integrated care for multi-morbidity assessed in systematic reviews: a scoping review.

BACKGROUND: The prevalence of multi-morbidity is increasing globally. Integrated models of care present a potential intervention to improve patient and health system outcomes. However, the intervention components and concepts within different models of care vary widely and their effectiveness remains unclear. We aimed to describe and map the definitions, characteristics, components, and reported effects of integrated models of care in systematic reviews (SRs). METHODS: We conducted a scoping review of SRs according to pre-specified methods (PROSPERO 2019 CRD42019119265). Eligible SRs assessed integrated models of care at primary health care level for adults and children with multi-morbidity. We searched in PubMed (MEDLINE), Embase, Cochrane Database of Systematic Reviews, Epistemonikos, and Health Systems Evidence up to 3 May 2022. Two authors independently assessed eligibility of SRs and extracted data. We identified and described common components of integrated care across SRs. We extracted findings of the SRs as presented in the conclusions and reported on these verbatim. RESULTS: We included 22 SRs, examining data from randomised controlled trials and observational studies conducted across the world. Definitions and descriptions of models of integrated care varied considerably. However, across SRs, we identified and described six common components of integrated care: (1) chronic conditions addressed, (2) where services were provided, (3) the type of services provided, (4) healthcare professionals involved in care, (5) coordination and organisation of care and (6) patient involvement in care. We observed differences in the components of integrated care according to the income setting of the included studies. Some SRs reported that integrated care was beneficial for health and process outcomes, while others found no difference in effect when comparing integrated care to other models of care. CONCLUSIONS: Integrated models of care were heterogeneous within and across SRs. Information that allows the identification of effective components of integrated care was lacking. Detailed, standardised and transparent reporting of the intervention components and their effectiveness on health and process outcomes is needed.

Community Health Worker-Led Cardiovascular Disease Risk Screening and Referral for Care and Further Management in Rural and Urban Communities in Rwanda.

Cardiovascular disease (CVD) is a global health issue. Low- and middle-income countries (LMICs) are facing early CVD-related morbidity. Early diagnosis and treatment are an effective strategy to tackle CVD. The aim of this study was to assess the ability of community health workers (CHWs) to screen and identify persons with high risks of CVD in the communities, using a body mass index (BMI)-based CVD risk assessment tool, and to refer them to the health facility for care and follow-up. This was an action research study conducted in rural and urban communities, conveniently sampled in Rwanda. Five villages were randomly selected from each community, and one CHW per each selected village was identified and trained to conduct CVD risk screening using a BMI-based CVD risk screening tool. Each CHW was assigned to screen 100 fellow community members (CMs) for CVD risk and to refer those with CVD risk scores ≥10 (either moderate or high CVD risk) to a health facility for care and further management. Descriptive statistics with Pearson's chi-square test were used to assess any differences between rural and urban study participants vis-à-vis the key studied variables. Spearman's rank coefficient and Cohen's Kappa coefficient were mainly used to compare the CVD risk scoring from the CHWs with the CVD risk scoring from the nurses. Community members aged 35 to 74 years were included in the study. The participation rates were 99.6% and 99.4% in rural and urban communities, respectively, with female predominance (57.8% vs. 55.3% for rural and urban, p-value: 0.426). Of the participants screened, 7.4% had a high CVD risk (≥20%), with predominance in the rural community compared to the urban community (8.0% vs. 6.8%, p-value: 0.111). Furthermore, the prevalence of moderate or high CVD risk (≥10%) was higher in the rural community than in the urban community (26.7% vs. 21.1%, p-value: 0.111). There was a strong positive correlation between CHW-based CVD risk scoring and nurse-based CVD risk scoring in both rural and urban communities, 0.6215 (p-value < 0.001) vs. 0.7308 (p-value = 0.005). In regard to CVD risk characterization, the observed agreement to both the CHW-generated 10-year CVD risk assessment and the nurse-generated 10-year CVD risk assessment was characterized as "fair" in both rural and urban areas at 41.6% with the kappa statistic of 0.3275 (p-value < 001) and 43.2% with kappa statistic of 0.3229 (p-value =0.057), respectively. In Rwanda, CHWs can screen their fellow CMs for CVD risk and link those with high CVD risk to the healthcare facility for care and follow-up. CHWs could contribute to the prevention of CVDs through early diagnosis and early treatment at the bottom of the health system.

African Control of Hypertension through Innovative Epidemiology and a Vibrant Ecosystem (ACHIEVE): novel strategies for accelerating hypertension control in Africa.

Hypertension is a leading preventable and controllable risk factor for cardiovascular and cerebrovascular diseases and the leading preventable risk for death globally. With a prevalence of nearly 50% and 93% of cases uncontrolled, very little progress has been made in detecting, treating, and controlling hypertension in Africa over the past thirty years. We propose the African Control of Hypertension through Innovative Epidemiology and a Vibrant Ecosystem (ACHIEVE) to implement the HEARTS package for improved surveillance, prevention, treatment/acute care of hypertension, and rehabilitation of those with hypertension complications across the life course. The ecosystem will apply the principles of an iterative implementation cycle by developing and deploying pragmatic solutions through the contextualization of interventions tailored to navigate barriers and enhance facilitators to deliver maximum impact through effective communication and active participation of all stakeholders in the implementation environment. Ten key strategic actions are proposed for implementation to reduce the burden of hypertension in Africa.

Feasibility and effectiveness of self-monitoring of blood glucose among insulin-dependent patients with type 2 diabetes: open randomized control trial in three rural districts in Rwanda.

BACKGROUND: The prevalence of type 2 diabetes in sub Saharan Africa (SSA) has been on the rise. Effective control of blood glucose is key towards reducing the risk of diabetes complications. Findings mainly from high-income countries have demonstrated the effectiveness of self-monitoring of blood-glucose (SMBG) in controlling blood glucose levels. However, there are limited studies describing the implementation of SMBG in rural SSA. This study explores the feasibility and effectiveness of implementing SMBG among patients diagnosed with insulin-dependent type 2 diabetes in rural Rwanda. METHODS: Participants were randomized into intervention (n = 42) and control (n = 38) groups. The intervention group received a glucose-meter, blood test-strips, log-book, waste management box and training on SMBG in addition to usual care. The control group continued with their usual care consisting of, routine monthly medical consultation and health education. The primary outcomes were adherence to the implementation of SMBG (testing schedule and recording data in the log-book) and change in hemoglobin A1c. Descriptive statistics and a paired t-test were used to analyze the primary outcomes. RESULTS: In both the intervention and control arms, majority of the participants were female (59.5% vs 52.6%) and married (71.4% vs 73.7%). Most had at most a primary level education (83.3% vs. 89.4%) and were farmers (54.8% vs. 50.0%). Among those in the intervention group, 63.4% showed good adherence to implementing SMBG based on the number of tests recorded in the glucose meter. Only 20.3% demonstrated accurate recording of the glucose level tests in log-books. The mean difference of the HbA1C from baseline to six months post-intervention was significantly better among the intervention group -0.94% (95% CI -1.46, -0.41) compared to the control group 0.73% (95% CI -0.09, 1.54) p < 0.001. CONCLUSION: Our study showed that among patients with insulin-dependent type 2 diabetes residing in rural Rwanda, SMBG was feasible and demonstrated positive outcomes in improving blood glucose control. However, there is need for strategies to enhance accuracy in recording blood glucose test results in the log-book. TRIAL REGISTRATION: The trial was registered retrospectively on the Pan African Clinical Trial Registry, on 17th May 2019. The registration number is PACTR201905538846394.

Population-Level Interventions Targeting Risk Factors for Hypertension and Diabetes in Rwanda: A Situational Analysis.

Background: Eighty percent (80%) of global Non-Communicable Diseases attributed deaths occur in low- and middle-income countries (LMIC) with hypertension and diabetes being key contributors. The overall prevalence of hypertension was 15.3% the national prevalence of diabetes in rural and urban was 7.5 and 9.7%, respectively among 15-64 years. Hypertension represents a leading cause of death (43%) among hospitalized patients at the University teaching hospital of Kigali. This study aimed to identify ongoing population-level interventions targeting risk factors for diabetes and hypertension and to explore perceived barriers and facilitators for their implementation in Rwanda. Methods: This situational analysis comprised a desk review, key informant interviews, and stakeholders' consultation. Ongoing population-level interventions were identified through searches of government websites, complemented by one-on-one consultations with 60 individuals nominated by their respective organizations involved with prevention efforts. Semi-structured interviews with purposively selected key informants sought to identify perceived barriers and facilitators for the implementation of population-level interventions. A consultative workshop with stakeholders was organized to validate and consolidate the findings. Results: We identified a range of policies in the areas of food and nutrition, physical activity promotion, and tobacco control. Supporting program and environment interventions were mainly awareness campaigns to improve knowledge, attitudes, and practices toward healthy eating, physical activity, and alcohol and tobacco use reduction, healthy food production, physical activity infrastructure, smoke-free areas, limits on tobacco production and bans on non-standardized alcohol production. Perceived barriers included limited stakeholder involvement, misbeliefs about ongoing interventions, insufficient funding, inconsistency in intervention implementation, weak policy enforcement, and conflicts between commercial and public health interests. Perceived facilitators were strengthened multi-sectoral collaboration and involvement in ongoing interventions, enhanced community awareness of ongoing interventions, special attention paid to the elderly, and increased funds for population-level interventions and policy enforcement. Conclusion: There are many ongoing population-level interventions in Rwanda targeting risk factors for diabetes and hypertension. Identified gaps, perceived barriers, and facilitators provide a useful starting point for strengthening efforts to address the significant burden of disease attributable to diabetes and hypertension.

How to Improve Awareness, Treatment, and Control of Hypertension in Africa, and How to Reduce Its Consequences: A Call to Action From the World Hypertension League.

Hypertension is the leading preventable risk factor for cardiovascular diseases and disability globally. In low- and middle-income countries hypertension has a major social impact, increasing the disease burden and costs for national health systems. The present call to action aims to stimulate all African countries to adopt several solutions to achieve better hypertension management. The following 3 goals should be achieved in Africa by 2030: (1) 80% of adults with high blood pressure in Africa are diagnosed; (2) 80% of diagnosed hypertensives, that is, 64% of all hypertensives, are treated; and (3) 80% of treated hypertensive patients are controlled. To achieve these aims, we call on individuals and organizations from government, private sector, health care, and civil society in Africa and indeed on all Africans to undertake a few specific high priority actions. The aim is to improve the detection, diagnosis, management, and control of hypertension, now considered to be the leading preventable killer in Africa.

Perceived cardiovascular disease risk and tailored communication strategies among rural and urban community dwellers in Rwanda: a qualitative study.

BACKGROUND: In Rwanda, cardiovascular diseases (CVDs) are the third leading cause of death, and hence constitute an important public health issue. Worldwide, most CVDs are due to lifestyle and preventable risk factors. Prevention interventions are based on risk factors for CVD risk, yet the outcome of such interventions might be limited by the lack of awareness or misconception of CVD risk. This study aimed to explore how rural and urban population groups in Rwanda perceive CVD risk and tailor communication strategies for estimated total cardiovascular risk. METHODS: An exploratory qualitative study design was applied using focus group discussions to collect data from rural and urban community dwellers. In total, 65 community members took part in this study. Thematic analysis with Atlas ti 7.5.18 was used and the main findings for each theme were reported as a narrative summary. RESULTS: Participants thought that CVD risk is due to either financial stress, psychosocial stress, substance abuse, noise pollution, unhealthy diets, diabetes or overworking. Participants did not understand CVD risk presented in a quantitative format, but preferred qualitative formats or colours to represent low, moderate and high CVD risk through in-person communication. Participants preferred to be screened for CVD risk by community health workers using mobile health technology. CONCLUSION: Rural and urban community members in Rwanda are aware of what could potentially put them at CVD risk in their respective local communities. Community health workers are preferred by local communities for CVD risk screening. Quantitative formats to present the total CVD risk appear inappropriate to the Rwandan population and qualitative formats are therefore advisable. Thus, operational research on the use of qualitative formats to communicate CVD risk is recommended to improve decision-making on CVD risk communication in the context of Rwanda.

Prevalence and characteristics associated with diabetes mellitus and impaired fasting glucose among people aged 15 to 64 years in rural and urban Rwanda: secondary data analysis of World Health Organization surveillance data.

Introduction: diabetes mellitus is an increasing public health burden in developing countries. The magnitude of diabetes association with traditional risk factors for diabetes have been given less attention in rural population. This study aims to determine the prevalence of diabetes and impaired fasting glucose and to assess associated characteristics to hyperglycemia in rural and urban Rwanda. Methods: this is a secondary analysis of data from a population-based cross-sectional study of 7240 people describing risk factors for non-communicable diseases using the WHO stepwise methods (STEPS). Relative frequencies of variables of interest were compared in rural and urban residence using Pearson chi-square tests. Diabetes and impaired fasting glucose were combined in a single hyperglycemia variable and odds ratios with 95% confidence intervals were used to explore associations between hyperglycemia, socio-demographic and health factors in urban and rural populations. Results: the prevalence in rural and urban areas was 7.5% and 9.7% (p.005) for diabetes and 5.0% and 6.2% for impaired fasting glucose (p.079) respectively. Obesity (AOR 2.57: CI: 0.86-7.9), high total cholesterol (AOR 3.83: CI: 2.03-7.208), hypertension (AOR 1.18: CI: 0.69-2.00), increasing age were associated with hyperglycemia in urban participants but only high total cholesterol and low high density lipoproteins (HDL) cholesterol were risk factors for hyperglycemia in rural participants. Conclusion: approximately one in six people in Rwanda have hyperglycemia. The magnitude of the association with traditional risk factors for diabetes differ in rural and urban settings. Different approaches to primary and secondary prevention of diabetes may be needed in rural populations.

Experience of Rwanda on COVID-19 Case Management: From Uncertainties to the Era of Neutralizing Monoclonal Antibodies.

The management of COVID-19 in Rwanda has been dynamic, and the use of COVID-19 therapeutics has gradually been updated based on scientific discoveries. The treatment for COVID-19 remained patient-centered and entirely state-sponsored during the first and second waves. From the time of identification of the index case in March 2020 up to August 2021, three versions of the clinical management guidelines were developed, with the aim of ensuring that the COVID-19 patients treated in Rwanda were receiving care based on the most recent therapeutic discoveries. As the case load increased and imposed imminent heavy burdens on the healthcare system, a smooth transition was made to enable that the asymptomatic and mild COVID-19 cases could continue to be closely observed and managed while they remained in their homes. The care provided to patients requiring facility-based interventions mainly focused on the provision of anti-inflammatory drugs, anticoagulation, broad-spectrum antibiotic therapy, management of hyperglycemia and the provision of therapeutics with a direct antiviral effect such as favipiravir and neutralizing monoclonal antibodies. The time to viral clearance was observed to be shortest among eligible patients treated with neutralizing monoclonal antibodies (bamlanivimab). Moving forward, as we strive to continue detecting COVID-19 cases as early as possible, and promptly initiate supportive interventions, the use of neutralizing monoclonal antibodies constitutes an attractive and cost-effective therapeutic approach. If this approach is used strategically along with other measures in place (i.e., COVID-19 vaccine roll out, etc.), it will enable us to bring this global battle against the COVID-19 pandemic under full control and with a low case fatality rate.

Implementing and Evaluating Community Health Worker-Led Cardiovascular Disease Risk Screening Intervention in Sub-Saharan Africa Communities: A Participatory Implementation Research Protocol.

The increasing burden of non-communicable diseases (NCDs), particularly cardiovascular diseases (CVD) in low- and middle-income countries (LMICs) poses a considerable threat to public health. Community-driven CVD risk screening, referral and follow-up of those at high CVDs risk is essential to supporting early identification, treatment and secondary prevention of cardiovascular events such as stroke and myocardial infarction. This protocol describes a multi-country study that aims to implement and evaluate a community health worker (CHW)-led CVD risk screening programme to enhance referral linkages within the local primary care systems in sub-Saharan Africa (SSA), using a participatory implementation science approach. The study builds upon a prior community-driven multicentre study conducted by the Collaboration for Evidence-based Health Care and Public Health in Africa (CEBHA+). This is a participatory implementation research. The study will leverage on the CVD risk citizen science pilot studies conducted in the four selected CEBHA+ project countries (viz. Ethiopia, Rwanda, Malawi, and South Africa). Through planned engagements with communities and health system stakeholders, CHWs and lay health worker volunteers will be recruited and trained to screen and identify persons that are at high risk of CVD, provide referral services, and follow-up at designated community health clinics. In each country, we will use a multi-stage random sampling to select and then screen 1000 study participants aged 35-70 years from two communities (one rural and one urban). Screening will be done using a simple validated non-laboratory-based CVD risk assessment mobile application. The RE-AIM model will be used in evaluating the project implementation outcomes, including reach, fidelity, adoption and perceived effectiveness. Developing the capacities of CHWs and lay health worker volunteers in SSA to support population-based, non-invasive population-based CVD risk prevention has the potential to impact on early identification, treatment and secondary prevention of CVDs in often under-resourced communities. Using a participatory research approach to implementing mobile phone-based CHW-led CVD risk screening, referral and follow-up in SSA will provide the evidence needed to determine the effectiveness of CVD risk screening and the potential for scaling up in the wider region.

Effects of integrated models of care for diabetes and hypertension in low-income and middle-income countries: a systematic review and meta-analysis.

OBJECTIVES: To assess the effects of integrated models of care for people with multimorbidity including at least diabetes or hypertension in low-income and middle-income countries (LMICs) on health and process outcomes. DESIGN: Systematic review. DATA SOURCES: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, Africa-Wide, CINAHL and Web of Science up to 12 December 2019. ELIGIBILITY CRITERIA: We included randomised controlled trials (RCTs), non-RCTs, controlled before-and-after studies and interrupted time series (ITS) studies of people with diabetes and/or hypertension plus any other disease, in LMICs; assessing the effects of integrated care. DATA EXTRACTION AND SYNTHESIS: Two authors independently screened retrieved records; extracted data and assessed risk of bias. We conducted meta-analysis where possible and assessed certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation. RESULTS: Of 7568 records, we included five studies-two ITS studies and three cluster RCTs. Studies were conducted in South Africa (n=3), Uganda/Kenya (n=1) and India (n=1). Integrated models of care compared with usual care may make little or no difference to mortality (very low certainty), the number of people achieving blood pressure (BP) or diabetes control (very low certainty) and access to care (very low certainty); may increase the number of people who achieve both HIV and BP/diabetes control (very low certainty); and may have a very small effect on achieving HIV control (very low certainty). Interventions to promote integrated delivery of care compared with usual care may make little or no difference to mortality (very low certainty), depression (very low certainty) and quality of life (very low certainty); and may have little or no effect on glycated haemoglobin (low certainty), systolic BP (low certainty) and total cholesterol levels (low certainty). CONCLUSIONS: Current evidence on the effects of integrated care on health outcomes is very uncertain. Programmes and policies on integrated care must consider context-specific factors related to health systems and populations. PROSPERO REGISTRATION NUMBER: CRD42018099314.

Community-driven citizen science approach to explore cardiovascular disease risk perception, and develop prevention advocacy strategies in sub-Saharan Africa: a programme protocol.

BACKGROUND: In sub-Saharan Africa (SSA), which experiences a disproportionately high cardiovascular disease (CVD) burden, population-based screening and prevention measures are hampered by low levels of knowledge about CVD and associated risk factors, and inaccurate perceptions of severity of risk. METHODS: This protocol describes the planned processes for implementing community-driven participatory research, using a citizen science method to explore CVD risk perceptions and to develop community-specific advocacy and prevention strategies in the rural and urban SSA settings. Multi-disciplinary research teams in four selected African countries will engage with and train community members living in rural and urban communities as citizen scientists to facilitate conceptualization, co-designing of research, data gathering, and co-creation of knowledge that can lead to a shared agenda to support collaborative participation in community-engaged science. The emphasis is on robust community engagement, using mobile technology to support data gathering, participatory learning, and co-creation of knowledge and disease prevention advocacy. DISCUSSION: Contextual processes applied and lessons learned in specific settings will support redefining or disassembling boundaries in participatory science to foster effective implementation of sustainable prevention intervention programmes in Low- and Middle-income countries.

Socio-demographic and clinical characteristics of diabetes mellitus in rural Rwanda: time to contextualize the interventions? A cross-sectional study.

BACKGROUND: Existing prevention and treatment strategies target the classic types of diabetes yet this approach might not always be appropriate in some settings where atypical phenotypes exist. This study aims to assess the socio-demographic and clinical characteristics of people with diabetes in rural Rwanda compared to those of urban dwellers. METHODS: A cross-sectional, clinic-based study was conducted in which individuals with diabetes mellitus were consecutively recruited from April 2015 to April 2016. Demographic and clinical data were collected from patient interviews, medical files and physical examinations. Chi-square tests and T-tests were used to compare proportions and means between rural and urban residents. RESULTS: A total of 472 participants were recruited (mean age 40.2 ± 19.1 years), including 295 women and 315 rural residents. Compared to urban residents, rural residents had lower levels of education, were more likely to be employed in low-income work and to have limited access to running water and electricity. Diabetes was diagnosed at a younger age in rural residents (mean ± SD 32 ± 18 vs 41 ± 17 years; p < 0.001). Physical inactivity, family history of diabetes and obesity were significantly less prevalent in rural than in urban individuals (44% vs 66, 14.9% vs 28.7 and 27.6% vs 54.1%, respectively; p < 0.001). The frequency of fruit and vegetable consumption was lower in rural than in urban participants. High waist circumference was more prevalent in urban than in rural women and men (75.3% vs 45.5 and 30% vs 6%, respectively; p < 0.001). History of childhood under-nutrition was more frequent in rural than in urban individuals (22.5% vs 6.4%; p < 0.001). CONCLUSIONS: Characteristics of people with diabetes in rural Rwanda appear to differ from those of individuals with diabetes in urban settings, suggesting that sub-types of diabetes exist in Rwanda. Generic guidelines for diabetes prevention and management may not be appropriate in different populations.

Chronic care service delivery models for people living with type 1 diabetes in low- and lower-middle income countries: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to map the published literature that describes the distribution and organization of chronic care service delivery models for people living with type 1 diabetes (PLWT1D) in low- and lower-middle-income countries (LLMICs). INTRODUCTION: Type 1 diabetes is an autoimmune condition commonly diagnosed in childhood and early adolescence; it cannot be prevented and is deadly without daily insulin injections. Among PLWT1D, the islet cells in the pancreas produce insufficient amounts of the glucose-regulating hormone, insulin, resulting in the need for chronic insulin replacement therapy. Epidemiological information regarding type 1 diabetes (T1D) is limited in LLMICs. Improving survival for PLWT1D in LLMICs requires early diagnosis and greater access to high quality chronic care service delivery models for T1D. The identification and reporting of service delivery model typologies for PLWT1D will allow for more specific research questions regarding individual typologies in subsequent systematic reviews. INCLUSION CRITERIA: The review will consider all types of literature on the organization and distribution of chronic care services for the management of PLWT1D provided out of facilities in LLMICs, published from 2000 to the present. METHODS: The JBI methodology for conducting scoping reviews will be employed. The search will be implemented across PubMed, Embase, and Web of Science. Full texts of the publications selected will be reviewed and data will be extracted through a charting table. The findings will be charted to summarize the results.

Implementation of blood glucose self-monitoring among insulin-dependent patients with type 2 diabetes in three rural districts in Rwanda: 6 months open randomised controlled trial.

INTRODUCTION: Most patients diagnosed with diabetes in sub-Saharan Africa (SSA) present with poorly controlled blood glucose, which is associated with increased risks of complications and greater financial burden on both the patients and health systems. Insulin-dependent patients with diabetes in SSA lack appropriate home-based monitoring technology to inform themselves and clinicians of the daily fluctuations in blood glucose. Without sufficient home-based data, insulin adjustments are not data driven and adopting individual behavioural change for glucose control in SSA does not have a systematic path towards improvement. METHODS AND ANALYSIS: This study explores the feasibility and impact of implementing self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes in rural Rwandan districts. This is an open randomised controlled trial comprising of two arms: (1) Intervention group-participants will receive a glucose metre, blood test strips, logbook, waste management box and training on how to conduct SMBG in additional to usual care and (2) Control group-participants will receive usual care, comprising of clinical consultations and routine monthly follow-up. We will conduct qualitative interviews at enrolment and at the end of the study to assess knowledge of diabetes. At the end of the study period, we will interview clinicians and participants to assess the perceived usefulness, facilitators and barriers of SMBG. The primary outcomes are change in haemoglobin A1c, fidelity to SMBG protocol by patients, appropriateness and adverse effects resulting from SMBG. Secondary outcomes include reliability and acceptability of SMBG and change in the quality of life of the participants. ETHICS AND DISSEMINATION: This study has been approved by the Rwanda National Ethics Committee (Kigali, Rwanda No.102/RNEC/2018). We will disseminate the findings of this study through presentations within our study settings, scientific conferences and publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: PACTR201905538846394; pre-results.

Screening strategies for hypertension.

BACKGROUND: Hypertension is a major public health challenge affecting more than one billion people worldwide; it disproportionately affects populations in low- and middle-income countries (LMICs), where health systems are generally weak. The increasing prevalence of hypertension is associated with population growth, ageing, genetic factors, and behavioural risk factors, such as excessive salt and fat consumption, physical inactivity, being overweight and obese, harmful alcohol consumption, and poor management of stress. Over the long term, hypertension leads to risk for cardiovascular events, such as heart disease, stroke, kidney failure, disability, and premature mortality. Cardiovascular events can be preventable when high-risk populations are targeted, for example, through population-wide screening strategies. When available resources are limited, taking a total risk approach whereby several risk factors of hypertension are taken into consideration (e.g. age, gender, lifestyle factors, diabetes, blood cholesterol) can enable more accurate targeting of high-risk groups. Targeting of high-risk groups can help reduce costs in that resources are not spent on the entire population. Early detection in the form of screening for hypertension (and associated risk factors) can help identify high-risk groups, which can result in timely treatment and management of risk factors. Ultimately, early detection can help reduce morbidity and mortality linked to it and can help contain health-related costs, for example, those associated with hospitalisation due to severe illness and poorly managed risk factors and comorbidities. OBJECTIVES: To assess the effectiveness of different screening strategies for hypertension (mass, targeted, or opportunistic) to reduce morbidity and mortality associated with hypertension. SEARCH METHODS: An Information Specialist searched the Cochrane Register of Studies (CRS-Web), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Latin American Caribbean Health Sciences Literature (LILACS) Bireme, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) without language, publication year, or publication status restrictions. The searches were conducted from inception until 9 April 2020. SELECTION CRITERIA: Randomised controlled trials (RCTs) and non-RCTs (NRCTs), that is, controlled before and after (CBA), interrupted time series (ITS), and prospective analytic cohort studies of healthy adolescents, adults, and elderly people participating in mass, targeted, or opportunistic screening of hypertension. DATA COLLECTION AND ANALYSIS: Screening of all retrieved studies was done in Covidence. A team of reviewers, in pairs, independently assessed titles and abstracts of identified studies and acquired full texts for studies that were potentially eligible. Studies were deemed to be eligible for full-text screening if two review authors agreed, or if consensus was reached through discussion with a third review author. It was planned that at least two review authors would independently extract data from included studies, assess risk of bias using pre-specified Cochrane criteria, and conduct a meta-analysis of sufficiently similar studies or present a narrative synthesis of the results. MAIN RESULTS: We screened 9335 titles and abstracts. We identified 54 potentially eligible studies for full-text screening. However, no studies met the eligibility criteria. AUTHORS' CONCLUSIONS: There is an implicit assumption that early detection of hypertension through screening can reduce the burden of morbidity and mortality, but this assumption has not been tested in rigorous research studies. High-quality evidence from RCTs or programmatic evidence from NRCTs on the effectiveness and costs or harms of different screening strategies for hypertension (mass, targeted, or opportunistic) to reduce hypertension-related morbidity and mortality is lacking.

Integration of Chronic Oncology Services in Noncommunicable Disease Clinic in Rural Rwanda.

Background: In rural sub-Saharan Africa, access to care for severe non-communicable diseases (NCDs) is limited due to myriad delivery challenges. We describe the implementation, patient characteristics, and retention rate of an integrated NCD clinic inclusive of cancer services at a district hospital in rural Rwanda. Methods: In 2006, the Rwandan Ministry of Health at Rwinkwavu District Hospital (RDH) and Partners In Health established an integrated NCD clinic focused on nurse-led care of severe NCDs, within a single delivery platform. Implementation modifications were made in 2011 to include cancer services. For this descriptive study, we abstracted medical record data for 15 months after first clinic visit for all patients who enrolled in the NCD clinic between 1 July 2012 and 30 June 2014. We report descriptive statistics of patient characteristics and retention. Results: Three hundred forty-seven patients enrolled during the study period: oncology - 71.8%, hypertension - 10.4%, heart failure - 11.0%, diabetes - 5.5%, and chronic respiratory disease (CRD) - 1.4%. Twelve-month retention rates were: oncology - 81.6%, CRD - 60.0%, hypertension - 75.0%, diabetes - 73.7%, and heart failure - 47.4%. Conclusions: The integrated NCD clinic filled a gap in accessible care for severe NCDs, including cancer, at rural district hospitals. This novel approach has illustrated good retention rates.